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nity health centers, which are empowering, mediating-type of institutions that work with people face to face. You have done that as the employer. In other words, you have initiated this and so it has worked.

Do you have any suggestions along those lines? How might we accomplish that as we change Medicare policy, not just saying this is where we want to go and this is the funding we are providing or the barriers we are removing, but how do we still ensure that somebody is getting in contact with these patients and doing these things? Can we rely on hospitals, who are organized also along the traditional medical model, for example, to do that? Do we need to do more than just change reimbursement incentives for them? Do any of you have any ideas along these lines?

Ďr. ÉVANS. I just might say that in most states there already is a well developed infrastructure for dealing with seniors. I am really talking about Medicare beneficiaries and those are typically senior centers and Triple A's. Triple A's are often the line that supplies nutrition services to older people, but often not many other services.

We have attempted to deliver exercise programs through Triple A's, and what we do is we go in and we train peer leaders, and they can be—just people from the community or Triple A employees—and in every place that we have done that the Triple A's say well not too many people are interested in this. They get five or six times more older people joining these programs than they ever anticipated. So I think that there is a great desire of older people to improve their health. They know what is looming. You know, they don't want to access health care dollars as much as we don't want them to. They want to improve their health. They just don't have access to it.

So I think that there is an already developed infrastructure that we can develop delivery these programs through at a relatively low cost, but we need some I think political will to be able to deliver these types of programs.

Senator TALENT. So you are suggesting working through Older American Act institutions, which would seem to be a commonsense first step.

Dr. EVANS. I believe so. The infrastructure is already there. They have access to millions of elderly people right now. They are trusted and then working through the state agencies. Most state agencies, like Arkansas, has a Department of Health that now is interested in senior health. They have a Department of Aging that usually interacts more with the Triple A's. So I think that instead of creating a new infrastructure, there is one already available.

Senator TALENT. Anybody else have comments?
Dr. WOOLF. I agree, although I-

Senator TALENT. If you disagree with my premise, by all means, say so.

Dr. WOOLF. I don't disagree, Senator. In fact, I think you are heading in the right direction. I think that we definitely need to provide those social support systems in order to help seniors navigate the system. The problem is that there is tremendous fragmentation in our system currently. Although Area Agencies on aging and other senior centers that exist in most communities are there for that purpose, as a primary care physician, I can tell you that there is a big divide and wall sometimes in between their world and the medical care delivery system, not that either one doesn't want to reach out to the other, but the infrastructure for those connections is not well developed.

What we really need is an infrastructure that integrates the different components of the community that need to support the senior in promoting healthy behaviors and in getting health care services. All the pieces are there, it is tying them together that is necessary. My practical suggestion: there is already work that CDC is doing through the STEPS Program that was initiated in recent years, where communities and regions around the country are testing these models for integration. Continuing to support that kind of innovation and creativity in communities and then extrapolating and generalizing those models out more broadly I think has real promise to tap the resources that are available in the community.

Senator TALENT. Yes. We have been supporting through grants the naturally occurring retirement community program that our local Jewish community has been doing within its community. I think it is largely what you are talking about, an attempt to integrate services and service providers in these institutions that deal with seniors or with whom seniors interact, so that we can collect what is out there and send consistent and healthy messages to seniors that way. It is just so difficult to get it from our minds here into legislation that will then produce the right results.

I think we are going to have to figure out some way to get the traditional medical providers on board and enthusiastic about this, and then it may naturally happen. I don't know whether it is reimbursement changes or pilots as with the Medicare Modernization Act but I think it is the key to getting this idea in the community. Mr. Brown, it is your turn.

Mr. BROWN. The market forces for the traditional health care provider world are not in the direction of prevention and reducing hospital admissions. They are really in the opposite direction, and that is one of the problems. If we go to a hospital administrator and say we have a program that can help you reduce hospital admissions by 50 percent, most hospital administrators look at that and say I am not sure that is a good idea for my business.

We actually have worked with hospitals linked to community health centers and have worked with case management programs where nurses and case managers and social workers tried to coach and monitor patients at home to prevent hospital admissions, and those programs were at least for uninsured patients and were seen as cost effective for the hospital.

But when you get to the sort of bread and butter business of a hospital, the business model is around the existing DRGs and codes and how they get paid. This isn't in there. Prevention is not in there. In fact, there are a lot of disincentives for it from an economic perspective.

If you look at the DRG and now they have designed so, you know, if you are readmitted within 30 days, the hospital pays the bill still

. If you have got somebody who gets admitted to the hospital three times in a year, that is 3 months out of the year that the hospital worries about that patient from an economic perspective, and 9 months out of the year where the hospital has really no interest economically in that patient.

That is a lot of discontinuity, and that gap needs to be bridged. There may be ways to do this through reimbursement mechanisms or through tweaks of the existing way things are coded. But somehow that gap has to be filled

Senator TALENT. People have talked about paying for performance type, which, if you could define the outcomes that you wanted in the proper way so it didn't have negative side effects, has potential because it creates an impetus within the system to produce a healthier result for seniors. But defining that, I think, would be difficult so that you don't get a negative.

Well, Mr. Chairman, I am not-I have probably trespassed on my time already. Thank you for calling the hearing.

Senator KOHL. Thank you, Senator Talent.
Senator TALENT. Thank you all for your work.

Senator Kohl. Gentlemen, we thank you very much for your participation here today and thank you very much for your expertise.

We appreciate very much what you have said as we continue to look forward to find ways to contain the growth in Medicare, primarily by helping seniors and people throughout our society lead healthier lifestyles.

Thank you so much, and this hearing is adjourned.
[Whereupon, at 11:35 a.m., the committee was adjourned).

APPENDIX

PREPARED STATEMENT OF SENATOR JAMES TALENT Thank you, Mr. Chairman, for convening this important hearing to examine the role of prevention in the Medicare program.

I cannot over emphasize the importance of disease management services to help seniors live longer, more productive lives with the additional benefit of saving Medicare dollars. I have traveled all around my home state of Missouri visiting with seniors on Medicare, and discussing the beneficial disease management provisions in the Medicare Modernization Act, which I supported.

Nearly half of all Americans live with chronic illnesses such as hypertension, asthma, diabetes, and heart disease. Approximately 78 percent of Medicare beneficiaries have at least one chronic disease, while 32 percent have four or more chronic conditions. Individuals with multiple chronic conditions are more likely to be hospitalized, fill more prescriptions, and have more physician and home health visits. Nearly two-thirds of all Medicare spending is for beneficiaries with five or more chronic conditions.

We know that approximately five percent of the costliest Medicare beneficiaries consume about half of total Medicare spending. That is why I advocated for Senate provisions in the Medicare Modernization Act to create demonstration projects to examine disease management and care coordination for our nation's seniors and the disabled. I continue to support this legislation, and look forward to next year when the full Medicare benefit goes into effect as I believe it will help millions of seniors in Missouri and across our country lead healthier lives.

QUESTIONS FROM SENATOR BLANCHE LINCOLN FOR MR. EVANS Question. Do adequate performance measures exist that cross multiple aspects of disease, such as function?

Answer. Yes, functional capacity in elderly people is a very powerful predictor of mortality, morbidity, and risk of admission to nursing home. Dr. Jack Guralnik at the National Institute on Aging has developed what he terms the short physical performance battery (SPPB) (3) that is easy to perform, even in a doctors office and should be used by physicians in examining their geriatric patients. The test consists of a 6-meter walk time, chair stand time (how long it takes to stand up from a seated position) and a balance test. Guralnik and his co-workers (2) have demonstrated that among nondisabled older people living in the community, objective measures of lower-extremity function were highly predictive of subsequent disability. Disability among elderly people is associated with increased hospitalization and a greatly increased cost to Medicare. These studies reveal that early identification of functional problems and treatment has the potential of preventing disability. The SPPB should be a standard component of a geriatric assessment.

Question. How would one identify those who might benefit most from nutrition and exercise interventions in terms of health and cost-savings, such as certain frail elderly persons? And should we target these interventions to those with multiple chronic illnesses (including diabetes and chronic Heart Failure) to obtain the “biggest Bang for the buck” in our “high cost” Medicare beneficiaries? This secondary prevention approach might be easier and cheaper to implement in a smaller group of chronically ill seniors. If so, do you think legislation allowing for a new Medicare care coordination benefit, such as the Geriatric and Chronic Care Management Act I have introduced, achieves this goal?

Answer. It is clear that there are a number of geriatric problems that may be identified before they develop into serious of life-threatening issues. There is only one way of identifying the potential problems in a comprehensive way and that with a geriatric assessment. In this way correctible nutritional problems, functional limitations, infections, over prescription of medication, and other problems may be iden

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